In 2016, I received one of my oddest cases yet. That was when I was introduced to “Ms. X” and the little green men only she could see.

Ms. X, who was in her 70s, had been seeing visions of various objects and creatures for about a year. She particularly reported seeing “little green men” that resembled the appearance of plastic toy soldiers (the kind from “Toy Story”) that would run around her cabinets and furniture; they never harmed or bothered her, but they were very distracting. Her case was referred to me for evaluation, at the University of Chicago, by her primary care physician. This physician knew something wasn’t right with Ms. X but didn’t want to send her for psychiatric treatment without ruling out a treatable eye disease.

PHYSICAL OR MENTAL?

When I first met Ms. X, I noticed that she was very calm and seemed perfectly aware that these green men were not real, despite the pervasiveness of the visions. This suggested to both her PCP and me that the problem with her was physical, not psychological. She spoke with calmness and clarity that indicated she overall had good mental faculties, other than these hallucinations.

On exam, I noted that Ms. X had dense cataracts, with vision being 20/400 in both eyes, without any other ocular pathology. I felt there was certainly a reason to operate on the cataracts regardless of her green men; worst-case scenario, maybe the visions would still be there but at least she could see more clearly otherwise.

When I told her about the diagnosis and proposed surgery, she was agreeable, but several family members, particularly her sister, were against it, insisting that she needed more serious psychiatric help instead of cataract surgery. Eventually, Ms. X proceeded with the procedure.

NO MORE GREEN MEN

I was pleasantly surprised that, after performing surgery in her first eye, she reported that her “hallucinations” went away entirely. She was very happy with the improved vision.

I realized that Ms. X likely suffered from Charles Bonnet Syndrome. While I had read about this in textbooks, this was the first such patient I had with that condition. Charles Bonnet Syndrome causes patients with long-standing poor vision to have hallucinations, especially of small figures (“Lilliputian” hallucinations). The key finding is that patients have very good insight that their hallucinations are not real — such as Ms. X’s little green men.

We did her second eye a few weeks later and again, she was very pleased with the result, though she felt sad that “my little green men have left me all alone now”.

Not only did I feel good about helping Ms. X improve her vision, but I also saved her from the possibility of needless psychiatric treatment. The most important lesson I got from this is to never underestimate the impact of ocular disease on a patient’s quality of life. As eye doctors, we often only focus on vision, but our work can also affect the entire body and really improve a patient’s daily life.

Ms. X is still a patient of mine and comes in every six to 12 months for a check-up. Each time she laughs and says, “My little green men are gone.” OM